FEDERAL AND STATE PROGRAMS

SSI, SSDI, MEDICAID, MEDICARE

Often a family will support an adult child who is mentally ill for a long period of time.  Sometimes this requires the use of precious savings, which may not be necessary.  Many do not realize that mental illness qualifies as a disability and that the disabled individual may be eligible for income and healthcare assistance. 

There are two federal disability programs: SSI (Supplemental Security Income) and SSDI (Social Security Disability Income).  The SSDI program is designated for people living with a disability.  Application can be made at any local Social Security office.  For information or appointment at the local Social Security office, call 1-800-772-1213 weekdays.  Information you may need in contacting the Social Security office might be the individual’s birth certificate or other proof of age and citizenship, information about the home where he or she lives, work history, any sources of financial support, dates of any military service and names, addresses, phone numbers of doctors, hospitals, clinics and institutions where treatment has been received, with dates of treatment.  Requirements of the department change and some information may no longer be needed. 

Eligibility

The amount paid under SSI and SSDI varies, and some individuals are eligible for both sources of funding. Those who live independently may receive a larger amount than those who are supported at a relative’s home. To be eligible for SSI based on disability, a person must have a physical or mental impairment. In the case of a child, the impairment should prevent the child from performing normal activities of daily living.  In the case of an adult, the disability would prevent the adult from doing any substantial gainful work.  The disability of either a child or adult is expected to last at least a year or to result in death.  In both the cases of the adult or child, the individual or family has little or no income or resources.  To be eligible for SSDI the person must: have worked and paid Social Security, or be an unmarried son or daughter (with rare exception) who became disabled before age 22, who has a parent eligible for retirement / disability/ death benefits.  The disable child does not have to be dependant or financially supported by the parent.  The recipient must also have a physical or mental impairment that prevents the person from doing any substantial gainful work that has lasted or is expected to last for at least one year. 

APPLICATION FOR SSI AND SSDI FUNDING

Benefits are retroactive only to the date of application, so it is important to apply as early as possible and plan a persistent follow up.  The application process can be expedited if medical records are obtained in advance.  This includes hospitalization as well as physician, case managers, etc. records.  An individual can be assisted in this process if a release is signed by the patient to allow a family member or authorized representative to assist.  Applications should include a listing of all physical and mental conditions that may be considered as disabilities.  The Social Security Administration has to consider multiple disabilities when assessing eligibility for benefits. 

If benefits are denied, the ruling may be appealed by requesting: (1) reconsideration, (2) a hearing before an administrative law judge, (3) a review of the decision by the appeals councils, or (4) civil action in a federal district court.  There is a 60-day appeal time period between each of these steps.  There is a National Organization of Social Security Claimants who helps individuals find representatives to handle SSA Appeals at 1-800-431-2804.  The Departments of Legal Aid around the state handle SSA appeals and waiver requests usually without cost, when the case is ready to go for the third appeal in front of an administrative law judge. 

Many consumers and their families find it a difficult task to obtain the required papers and information and to work their way through the application and review process.  There are attorneys who specifically handle these types of cases.  While waiting on a decision on eligibility for SSI or SSDI, a disabled person may qualify for State Disability Assistance (SDA), food stamps, or assistance with emergency food and shelter through the Department of Social Services (DSS).

Importantly, when an individual applies for SSI or SSDI, they can request SSA assess them for presumptive disability (PD).  This will give an individual the opportunity to receive SSI and Medicaid for three months while Social Security is processing their claim for benefits.  PD should be requested in writing and usually can be considered if it is obvious that an individual is too disabled to work for longer than a year.  If an individual is not found eligible, repayment is not required.  The Disability Determinations staff is required to make an eligibility decision usually within 90-days. 

It may be desirable to have a representative designated to receive payments if the individual with the mental illness is unable to manage his or her funds.  This representative may be a relative or an agency or some other designated individual.  Family should consider designating someone outside of the family to handle funds so that they can concentrate on support and care. 

There is provision for SSI and SSDI payments to continue for a limited time while the individual is in a hospital or other institution.  This is designated to assist the person to maintain existing housing arrangements during a short period of hospitalization.  Applications for this benefit must be made to the Social Security office. 

Under many circumstances, Medicaid is available for those who qualify for SSI.  In Florida, Medicaid application can be made at any district office of the Department of Children and Families. 

CONSERVATORSHIP

Conservatorship is the designation by the Probate Court of a person to manage substantial income or property for another person.  However, if the only income is from SSI or SSDI, conservatorship is not necessary.  In this case, a parent or other person can be appointed representative payee by the Social Security office to handle financial matters. 

WILLS, TRUSTS AND ESTATE PLANNING

If an individual with mental illness qualifies for SSI benefits, it is very important for the family to plan ahead so that SSI payment and Medicaid will not be lost through inadequate estate planning.  By inheriting property or money, the individual may be disqualified for these entitlements, which cover the cost of residential services and medical care.  Some families have drawn up a will, which disqualifies the relative who is mentally ill.  Others have set up a Special Needs Trust with another relative as trustee, or with a financial institution and another relative as co-trustee.  The Special Needs Trust must be restricted so that it cannot be used for basic living costs; a lawyer who specializes in this work should be consulted. 

Supplemental Needs Trust – Many parents are not aware that special planning tools are available to protect assets for disabled family members.  A Supplemental Needs Trust is a special trust designed to provide funds for a disabled individual’s needs without putting public benefits at risk.  Parent can establish these trusts during life or through carious estate plans.  

Supplemental Needs Trusts are used to shelter funds for the benefit of the disabled person.  These funds are typically the result of an inheritance or personal injury award.  Funds are available for anything not provided by public benefits.  Within a properly drafted trust, the funds are not considered in determining eligibility for public benefits. 

Proper estate planning includes not only planning for others after a caregiver’s death, but also planning for the caregiver during his or her lifetime.  The family must plan for the possibility that the caregivers themselves could become disabled as they age.  There are many ways to make certain that the estate is preserved for the disabled child whiles still meeting the needs of the caregiver during their lifetime. 

Consult an attorney who specializes in these issues, as laws can change. 

MEDICARE

Medicare is a health insurance program for people age 65 or older, certain people with disabilities who are under age 65 and people who have permanent kidney failure.  Medicare provides basic protection against the cost of health care, but it does not cover all medical expenses or the cost of long –term care.    Medicare and Medicaid are not the same program.  Medicare is operated as a joint venture between federal and state governments.

Medicare has three parts: Part A – Hospital Insurance , which helps pay for inpatient care in a hospital and skilled nursing facilities, home health care and hospice care; Part B – Medical Insurance, which helps pay for doctor’s services, out-patient hospital care and many other medical services and supplies; Part D, which pays for drugs.  Medicare covers a number of health care needs, some of which require co-pays.  For a detailed explanation of Medicare services available and on how to apply, go to Medicare’s website at www.medicare.gov or The Center for Medicare and Medical Services at www.cms.hhs.gov.  You may also call 1-800-Medicare (800-633-4237). 

Medicare Costs

There is a monthly premium for Medicare services and other out-of-pocket costs.  When services are delivered, a deductible or co-pay may apply.  If someone cannot afford to pay the Medicare premiums and other costs, he or she may also get help from the state through an assistance program.  Assistance programs are for people who are entitled to Medicare and who have very low income. 

MEDICAID

Medicaid, a program funded with federal and state dollars, helps people who cannot afford medical care, such as people who have a low income and have limited savings accounts and other assets.  It is for people of any age.  It usually covers the full cost of health care in some cases; patients may share a part of the cost.  If someone qualifies for Medicare, he or she may also be qualified for Medicaid depending upon income and other related factors.  The federal government sets general guidelines for Medicaid, but each state legislature decides:

• Who qualifies for Medicaid
• What services will be covered
• How much to pay for the services
• How to run the Medicaid program

In Florida, eligibility is determined by the Florida Department of Children and Families and the Medicaid program is ran by the Agency for Healthcare Administration. 

the reform as approved by the federal government is being piloted in two counties, Duval and Broward.  Successful roll out of reform in those two counties will result in subsequent reform activities in the

Florida’s Medicaid Reform

In 2005, the state of Florida sought and received a waiver from the federal government to allow reform of its Medicaid system.  As this guide goes to press, the reform as approved by the federal government is being piloted in two counties, Duval and Broward. Successful roll out of reform in those two counties will result in subsequent reform activities in the

remainder of Florida.  Medicaid Reform allows considerable flexibility in services available and involves Managed Care companies extensively in the process. 

The following is a short list of services that may be covered differently in different parts of Florida depending on the Medicaid program operating in the area.

·         Community mental health services

·         Prescription drugs

·         Vision exams and glasses

·         Hearing exams and hearing aids

·         Dental service

·         Home and community based services including AIDS services and assisted living for the aged and disabled

·         Adult health screenings for adults 21 and older

·         Hospice services

·         Care in intermediate care facilities for people who are developmentally disabled

·         Durable medical equipment and supplies including ambulatory equipment (canes, crutches, walkers, etc.)

·         Physical, occupational, respiratory and speech therapy

·         Ambulance and other transportation services

·         Special child health services

·         Under Medicaid Reform, the state has also authorized other services at the Managed Care Organization’s discretion

 WORK ACTIVITY 

There are several options available to individuals who are living with a disability and are able to and desire to work.  Assistance with education, training and employment may be found by contacting Florida’s Division of Vocational Rehabilitation at 866-515-3692.  Other programs available include the following: 

Tickets to Work – Persons who are current beneficiaries of Social Security may be eligible to participate in the Social Security Administration’s Ticket to Work program.  The “Ticket” is a voucher that can be used to obtain employment-related supports and services from approved service providers known as Employment Networks.  Tickets may also be placed with the Division of Vocational Rehabilitation.  Participation in the Ticket program is voluntary for both the Social Security beneficiary and the Employment Network. 

PASS Program – The Plan to Achieve Self Support (PASS) is an SSI program to help individuals with disabilities return to work.  PASS lets disabled individuals set aside money and / or assets he or she own to pay for item or services needed to achieve a specific work goal.  This could be a number of things and can include items such as supplies to start a business, school expenses, transportation, uniform requests and training among others.  In order to participate in the PASS program, an individual needs to contact the local SSA office and obtain a PASS form (SSA-545-BK).  Additional information can be obtained by contacting the Social Security Office. 

Client Assistance Program (CAP) – CAP is a program within The Advocacy Center for Persons with Disabilities.  It is a Federal Grant program and is designed to assist individuals with general information and referral on the Federal Disabilities Act and other disability related services available in Florida.  CAP can investigate, negotiate and pursue administrative, legal and other remedies to ensure that client rights are protected.  For more information on CAP, contact The Advocacy Center at 1-800-342-0823. 

Other employment assistance – There are other resources available to assist an individual with a mental illness in obtaining employment.  Organizations such as Abilities, Inc., Clubhouses, and others may be available along with the options many employers now offer to assist disabled individuals in finding meaningful work.  Individuals interested in finding other employment resources may contact NAMI Florida or The Advocacy Center for Persons with Disabilities, as well as individual employers in there are.